by Andrea Hartmann, PhD, Jennifer Greenberg, PsyD, & Sabine Wilhelm, PhD
Overview of CBT for BDD and its empirical support
Most patients with body dysmorphic disorder (BDD) do not seek psychiatric/psychological care, but look for costly surgical, dermatologic, and dental treatments to try to fix perceived appearance flaws (e.g., Phillips, et al., 2000), that often worsen BDD symptoms (e.g., Sarwer & Crerand, 2008). Two empirically-based treatments are available for the treatment of BDD: serotonin reuptake inhibitors (SRIs) (click here to learn more about medication treatment for BDD) and cognitive-behavioral therapy (CBT). Several studies have found CBT to successfully reduce BDD severity and related symptoms such as depression (McKay, 1999; McKay et al., 1997; Rosen et al., 1995; Veale et al., 1996; Wilhelm et al., 1999; Wilhelm et al., 2011; Wihelm et al., 2014).
CBT models of BDD (e.g., Veale, 2004; Wilhelm et al., 2013) incorporate biological, psychological, and sociocultural factors in the development and maintenance of BDD. The model proposes that individuals with BDD selectively attend to minor aspects of appearance as opposed to seeing the big picture. This theory is informed by clinical observations and neuropsychological (Deckersbach et al., 2000) and neuroimaging findings (Feusner et al., 2007; Feusner et al., 2010). Individuals with BDD also overestimate the meaning and importance of perceived physical imperfections. For example, when walking into a restaurant, a patient with BDD who has concerns about his nose might think, “Everyone in the restaurant is staring at my big, bulbous nose.” Patients are also more likely misinterpret minor flaws (e.g., perceived asymmetry) as major personal flaws (e.g., “If my nose is crooked, I am unlovable”) (Buhlmann et al., 2009; Veale, 2004). Self-defeating interpretations foster negative feelings (e.g., anxiety, shame, sadness) that patients try to neutralize with rituals (e.g., excessive mirror checking, surgery seeking) and avoidance (e.g., social situations). Because rituals and avoidance may temporarily reduce painful feelings they are negatively reinforced and thus maintain maladaptive beliefs and coping strategies.
CBT for BDD typically begins with assessment and psychoeducation, during which the therapist explains and individualizes the CBT model of BDD. In addition, CBT usually includes techniques such as cognitive restructuring, exposure and ritual prevention, and relapse prevention. Some CBT for BDD includes perceptual (mirror) retraining. A modular CBT manual (CBT-BDD; Wilhelm et al., 2013) has been developed to target core symptoms of BDD and to flexibly address symptoms that affect some, but not all, patients. Additional modules might address depression, skin picking/hair plucking, weight and shape concerns, and cosmetic surgery seeking (e.g. Wilhelm et al., 2013). CBT-BDD has been shown to be effective in open (Wilhelm et al., 2011) and randomized control trials (Wilhelm et al., 2014).
Assessment, motivational assessment, and psychoeducation
CBT begins with an assessment of BDD and associated symptoms. Clinicians should inquire about BDD-related areas of concern, thoughts, behaviors, and impairment. It is important to ask specifically about BDD symptoms as it often goes undetected in clinical settings (e.g., Grant et al., 2002) due to embarrassment and shame. Clinicians should be aware of clues in clinical presentation such as appearance (e.g., scarring due to skin picking) and behaviors (e.g, wearing camouflage), ideas or delusions of reference (e.g., feelings that people talk about them, stare at them), panic attacks (e.g., when looking into the mirror), depression, social anxiety, substance abuse and suicidal ideation as well as being housebound. Additionally, differential diagnosis should be clarified in a structured clinical interview including eating disorders, obsessive compulsive disorder, depression, and social phobia. Given the high rates of depression and suicidality in BDD, it is critical to evaluate depression and suicidality at the onset and regularly throughout treatment.
For patients reluctant to try CBT or who hold highly delusional appearance beliefs, the therapist should incorporate techniques from motivational interviewing (MI; Miller & Rollnick, 2003) that have been adapted for the use in BDD (Wilhelm et al., 2013). In a first step, the therapist should empathize with the patient’s body image-related distress instead of directly questioning the validity of the beliefs (“I see that you really suffer because you are so worried because of the way you look. Let’s try to reduce this distress.”). Also, non-judgmental Socratic questioning can be employed (“What might be the advantages of trying CBT for BDD?“). The therapist can also discuss the discrepancy between BDD symptoms and the patient’s goals (“What should your life look like 10 years from now?“). In particular, for patients with poor insight it might be more helpful to address the usefulness of beliefs instead of the validity (e.g., “Are your beliefs preventing you from participating in activities you enjoy?“). MI strategies often need to be used throughout treatment.
Next, the therapist should provide psychoeducation about BDD, such as its prevalence, common symptoms, and differences between body image and appearance. Then, the therapist and patient develop an individualized model of BDD based on the patient’s specific symptoms. Such models include theories of how body image problems develop (including biological, sociocultural and psychological factors) (Wilhelm et al., 2013). It is important to explore factors in the patient’s current life that are serving to maintain body image concerns, including triggers for negative thoughts about appearance, interpretations of these thoughts, emotional reactions, and (maladaptive) coping strategies. This will help to inform the treatment and which specific modules are needed.
Cognitive strategies include identifying maladaptive thoughts, evaluating them, and generating alternative thoughts. Therapists introduce patients to common cognitive errors in BDD, such as “all-or-nothing thinking” (e.g., “This scar makes me completely disgusting”) or “mindreading” (e.g., “I know my girlfriend wishes I had better skin”). Patients are then encouraged to monitor their appearance-based thoughts in and outside of the session and identify cognitive errors (e.g., “Why am I so nervous about riding the subway?” “I know others are staring at my nose and thinking how ugly it looks”. Cognitive distortion: “personalization”). After the patient has gained some skill in identifying maladaptive thoughts and cognitive errors, the therapist can start to evaluate thoughts with the patient (e.g., Rosen et al., 1995; Veale et al., 1996; Wilhelm et al., 2013). While it is often helpful to evaluate the validity of a maladaptive thought (e.g., “What is the evidence others are noticing or judging my nose?”), it can also be beneficial to examine its usefulness (e.g. “Is it really helpful for me to think that I can only be happy if my nose were straight?”; Wilhelm et al., 2013), particularly for patients with poor insight. Once the patient has become adept at identifying and restructuring automatic appearance-related beliefs, deeper level (core) beliefs should be addressed. Common core beliefs in BDD include I’m unlovable” or “I’m inadequate” (Veale et al., 1996). These deeply held beliefs filter a patient’s experiences, and if not addressed, can thwart progress and long-term maintenance of gains. Core beliefs often emerge during the course of therapy. They can also be identified using the downward arrow technique, which involves the therapist asking repeatedly about the worst consequences of a patient’s beliefs (e.g., for the thought “People will think that my nose is huge and crooked,” the therapist would ask the patient, “What would it mean if people noticed your nose was big/crooked?”) until the core belief is reached (e.g., “If people noticed that my nose was big/crooked, they wouldn’t like me and this would mean that I am unlovable.”; Wilhelm et al., 2013). Negative core beliefs can be addressed through cognitive restructuring, behavioral experiments, and strategies such as the self-esteem pie, which helps patients learn to broaden the basis of their self-worth to include non-appearance factors (e.g., skills, achievements, moral values).
Exposure and ritual prevention (E/RP)
Prior to beginning E/RP, the therapist and patient should review the patient’s BDD model to help identify the patient’s rituals (e.g., excessive mirror checking) and avoidance behaviors (e.g., avoiding riding the subway) and discuss the role of rituals and avoidance in maintaining his symptoms. The therapist and patient jointly develop a hierarchy of anxiety provoking and avoided situations. Patients often avoid daily activities, or activities that could reveal one’s perceived flaw, including shopping (e.g., changing in a dressing room), going to the beach, intimate sexual encounters, going to work or class, or accepting social invitations. The hierarchy should include situations that would broaden a patient’s overall social experiences. For example, a patient might be encouraged to go out with friends twice per week instead of avoiding friends on days when he thought his nose looked really “huge.” The first exposure should be mildly to moderately challenging with a high likelihood for success. Exposure can be very challenging for patients, therefore, it is important for the therapist to provide a strong rationale for exposure, validate the patient’s anxiety while guiding him towards change, be challenging and encouraging, be patient and a cheerleader, and quickly incorporate ritual prevention. To reduce rituals, patients are encouraged to monitor the frequency and contexts in which rituals arise. The therapist then teaches patients strategies to eliminate rituals by first learning how to resist rituals (e.g., waiting before checking the mirror) or reduce rituals (e.g., wearing less makeup when out in public). The patient should be encouraged to use ritual prevention strategies during exposure exercises. It is often helpful to set up exposure exercises as a “behavioral experiment” during which they evaluate the validity of negative predictions (e.g., if I don’t wear my hat, someone will laugh at my thinning hair”). The goal of E/RP is to help patients practice tolerating distress and acquire new information to evaluate their negative beliefs (Wilhelm et al., 2013).
Individuals with BDD often have a complex relationship with mirrors and reflective surfaces. A patient may vacillate between getting stuck for hours in the mirror scrutinizing, grooming, or skin picking, and active avoidance of seeing his reflection. Usually patients focus only on the body parts of concern and get very close to the mirror, which magnifies perceived imperfections and maintains maladaptive BDD beliefs and behaviors. Furthermore, patients tend to engage in judgmental and emotionally charged self-talk (“Your nose looks so disgusting”). Perceptual retraining helps to address distorted body image perception and helps patients learn to engage in healthier mirror-related behaviors (i.e., not getting too close to the mirror, not avoiding the mirror entirely). The therapist helps to guide the patient in describing his whole body (head to toe) while standing at a conversational distance from the mirror (e.g., two to three feet). Instead of judgmental language (e.g., “My nose is huge and crooked.”), during perceptual (mirror) retraining, patients learn to describe themselves more objectively (“There is a small bump on the bridge of my nose”). The therapist encourages the patient to refrain from rituals, such as zoning in on disliked areas or touching certain body parts. Perceptual retraining strategies can also be used to broaden patients attention in other situations in which the patient selectively attends to aspects of their and others’ appearance (e.g., while at work or out with friends). Patients are encouraged to practice attending to other things in the environment (e.g., the content of the conversation, what his meal tastes like) as opposed to his own or others’ appearance (Wilhelm et al., 2013).
Brief overview over additional modules
Specific treatment strategies may be necessary to address symptoms affecting some but not all patients including: skin picking/hair pulling, muscularity and shape/weight, cosmetic treatment, and mood management (Wilhelm et al., 2013). Habit reversal training can be used to address BDD-related skin picking or hair pulling. Patients with significant shape/weight concern, including those suffering from muscle dysmorphia often benefit from psychoeducation and cognitive-behavioral strategies tailored to shape/weight concerns. Therapists can use cognitive and motivational strategies to address maladaptive beliefs about the perceived benefits of surgery while at the same time helping the patient to nonjudgmentally explore the pros and cons of pursuing cosmetic surgery (Wilhelm et al., 2013). Depression is common in patients with BDD and may become treatment interfering (Gunstad & Phillips, 2003). Patients with significant depression can benefit from activity scheduling, as well as cognitive restructuring techniques for more severely depressed patients (Wilhelm et al., 2013).
Treatment ends with relapse prevention focused on consolidation of skills and helping patients plan for the future. Therapists help patients expect and respond effectively to upcoming challenges (e.g., starting college, job interview, dating). Therapists may recommend self-therapy sessions in which patients set time aside weekly to review skills and set upcoming BDD goals. Booster sessions can be offered after treatment ends as a way to periodically assess progress and review CBT skills as needed (Wilhelm et al., 2013).
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